Background/Purpose: Cardiac valve involvement in the APS is prevalent, necessitating valve surgery in about 5% of the patients. Data regarding valve surgery outcomes in APS relies on small case series and case reports with a mortality rate ranging from 12.5% to 40%. We aimed to describe the outcome and prognosis of cardiac valve surgery in patients with primary and secondary APS, and to determine factors associated with outcome.

Methods: All patients with APS, (primary or secondary to SLE), who underwent valve surgery at the Sheba-Tel-Hashomer or Tel Aviv Sourasky medical centers in Israel in the last 3 decades were included in this retrospective analysis. Data regarding clinical characteristics, valve involvement, treatment before surgery, type of valve used and early and late complications were collected and analyzed.

Results: We identified 23 patients who underwent cardiac valve surgery from 1992-2021. Of whom, 17 (73.9%) were female, median age at surgery was 45 years (range 18-71). Ten patients (43.5%) had APS secondary to SLE. The median time from APS diagnosis to valve surgery was 17 years (range 0-40). Triple positive aPL were noted in 16 of 21 patients (76.2%), and 19 of 21 (90.5%) had a positive lupus anticoagulant (LA).

The mitral valve (MV) was the most common valve affected (n=15, 65.22%), followed by the aortic valve (n=7, 30.43%). Findings compatible with Libman-Sacks endocarditis (LSE) were noted in 13 (56.52%) of the patients. Moderate-severe pulmonary hypertension was evident in 50% of the patients before surgery, and the mean New-York Heart Association score was 2.09.

A mechanical valve was used in 14 of 23 (60.87%) patients, one patient underwent MV repair and one tricuspid valve repair. One patient required concomitant coronary bypass surgery (CABG).

Mean follow up following surgery was 66.59±80.12 months.

Thirteen patients (56.52%) had an early (30 day post-surgery) complication, including 8 severe complications – 2 deaths, 2 post-pericardiotomy syndrome, valve infection, valve thrombosis, stroke and major bleeding (one of each). Eight of 20 patients ( 40%) had a late complication – one death (4 years after MV replacement); valve thrombosis; stroke and major bleeding; newly developed LSE; major bleeding; stroke; E. coli bacteremia and chronic pericarditis (one of each). All mortality cases occurred in patients with mechanical valves.

In a univariate analysis pre-surgical warfarin treatment (p=0.02) and valve repair (p=0.03) were associated with a better outcome (no complications or death). Whereas a past history of DVT (p=0.02), pre-surgical heparin treatment (p=0.009), and CABG (p=0.008) were linked with mortality.

Conclusion: In this cohort of APS patients from two tertiary centers in Israel the mortality rate was 13.04%, which was lower than some previous case series. The total complication rate was 73.91%.

We have identified possible predictors of outcome, however valve surgery in APS patients continues to carry a guarded prognosis. Larger studies and registries are needed to define risk factors for severe valvular involvement, the best surgical approach and medical treatment post-surgery.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/cardiac-valve-surgery-outcomes-in-the-antiphospholipid-syndrome/